Patient Health Questionnaire (PHQ9)

Patient Health Questionnaire (PHQ9)
Date

MonthDayYear
Date
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Over the last 2 weeks, how often have you been bothered by any of the following?
1. Little interest or pleasure in doing things*

Not at allSeveral daysMore than half the daysNearly everyday
2. Feeling down, depressed or hopeless*

Not at allSeveral daysMore than half the daysNearly everyday
3. Trouble falling or staying asleep, sleeping too much*

Not at allSeveral daysMore than half the daysNearly everyday
4. Feeling tired or having little energy*

Not at allSeveral daysMore than half the daysNearly everyday
5. Poor appetite or overeating*

Not at allSeveral daysMore than half the daysNearly everyday
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down*

Not at allSeveral daysMore than half the daysNearly everyday
7. Trouble concentrating on things, such as reading the newspaper or watching television*

Not at allSeveral daysMore than half the daysNearly everyday
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so figety or restless that you have been moving around a lot more than usual*

Not at allSeveral daysMore than half the daysNearly everyday
9. Thoughts that you would be better off dead, or of hurting yourself*

Not at allSeveral daysMore than half the daysNearly everyday
If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*

Not at allSeveral daysMore than half the daysNearly everyday
PHQ-9 Total Score:
PHQ-9 Severity:
Would you like to be contacted for a free 10-minute initial consultation?*

YesNo
Should be Empty:

Patient Health Questionnaire (PHQ9)

Over the last 2 weeks, how often have you been bothered by any of the following?